Faculty Handbook

Institutional Review Board Protocol Termination Report

For Office Use Only
Received date: Termination date:
PLEASE RETURN THE COMPLETED FORM TO THE Institutional Review board, c/o Office of Grant Programs, 321 Warner Hall.
     
Protocol Number: _________________________________________________________________________________
 
Principal Investigator: ______________________________________________________________________________
     
Protocol Title: ____________________________________________________________________________________
     
Brief description of the protocol:  
 
________________________________________________________________________________________________
 
________________________________________________________________________________________________
     
________________________________________________________________________________________________
     
________________________________________________________________________________________________
     
Brief description of the results of the protocol:  
     
________________________________________________________________________________________________
     
________________________________________________________________________________________________
 
________________________________________________________________________________________________
 
________________________________________________________________________________________________
 
Has this research resulted in any publications? _____ Yes _____ No
If yes, please submit a copy of the publication(s) to the IRB.
     
Number of subjects enrolled at WestConn: _____________
     
Number of subjects enrolled at another site: ____________
     
Please list the number of subjects who completed the study: At WestConn: ____________
  At another site: _____________
     
Serious Adverse Events:    
Have there been any serious adverse events on this protocol: _____ Yes _____ No
     
If yes, please list the number of adverse events ______    
     
Were these reported to the IRB? _____ Yes _____ No
     
If the events have not been reported, attach a completed Adverse Event Form.
     
Reason for Termination:    
       
_____ Protocol reached goals
_____ Protocol never received funding
_____ Principal investigator or major co-investigator left the institution
_____ Not enough subjects for project to be completed
_____ Protocol closed due to adverse reaction(s)
_____ Investigator lost interest in the study
_____ Other (please explain below)
   
  _____________________________________________________________________________________
   
  _____________________________________________________________________________________
   
  _____________________________________________________________________________________
I certify that as of the date below, subjects are no longer being studied or followed on this protocol and therefore this protocol should be officially terminated by the IRB.
Principal Investigator’s Signature: Date:
I have reviewed the termination report:
IRB Chair's Signature: Date:

Last updated: 6/27/06


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